I thank:
Professor G. ARVIS for the quality of
his teaching, his availability and valuable advice in the
editing of this work.
The lecturers of the diploma of
Andrology of the Faculty of Medicine of Saint-Antoine
(Paris).

Page 1 ---

Introduction

Being in charge for over ten years of the routine
examination of college freshmen as part of the preventive
medicine programme of the university, I diagnose a
significant number of phimoses among older children and young
adults.

Among this male population aged 18 to 22, we have observed
that nearly 10% have various degrees of tightness of the
foreskin, ranging from total inability to expose the glans to
a simple ring which gets stuck in the sulcus. In this report
the word phimosis is used to mean the diameter of the
inferior preputial ring is smaller than the diameter of the
erect glans.

From the interviews it appears that the great majority of
these subjects are virgin, and that among those who have had
sexual experience, many have failed, with difficulty in
penetration, pain and loss of erection; except perhaps in
cases of the tightest phimoses who were successful in penile
penetration with the glans covered. The remainder expose
themselves to considerable risks of paraphimosis by
persevering in intercourse. This possibility and the
difficulties in carrying out successful intercourse make it
necessary to intervene medically.

Page 2 ---

Treatment

The conventional treatment of phimosis is surgical:

Circumcision which removes the foreskin, or simple plastic
surgery which preserves the fold of skin but opens the
ring.

For a number of reasons I have come to reject this
therapeutic procedure:

* Surgical intervention:
- is traumatic, brutal, and irreversible
- necessitates anaesthesia
- is bloody.
These two latter features give rise to the possible
complications of any other form of surgery.
- in the case of circumcision reduces the mobility of the
penile skin; this factor is important and we shall return to
it at length on page
12.
- is psychologically stressful by cutting an organ which is
highly symbolic for a male at the dawn of his sexual
life.
- creates a mutilation: the amputation causes the penis to
differ from that of his friends at an age where he has
scarcely acquired knowledge of normality.
- causes brutal exposure of the mucous membrane by the
excision of the protection of the glans.
- interferes with the pattern of masturbation which may be
seriously traumatic.
- in the case of plastic surgery may fail due to scar
formation.
- is expensive and requires hospitalisation.

* Remodelling of the foreskin should be considered. It
is:
- logical: in medicine we only refer for surgery failures of
remodelling whether it be muscular, tendinous or
cutaneous.
- painless
- gradual
- unobtrusive
- free
- not traumatic or troublesome to the patient
- preserves the foreskin which has definite functions,
described on page
13.
- allows the preservation of patterns of masturbation.
- avoids the pain of the exposed glans.

Page 3 ---

Reflections

The study of observed cases reveals that adolescent or
young adult subjects suffering from phimosis have habits of
masturbation different from others.

Conventionally the pursuit of solitary pleasure is done
with the dominant hand closed over the penis making alternate
back and forth movement over the shaft, the hand going down
towards the pubis, uncovering the glans which the index
finger or thumb may now and then stroke lightly, reproducing
the sensation of intercourse.

This exercise results in moving the penile skin in the
same way as will occur in vaginal intercourse, and therefore
it is a preparation for adult sexual relations. We shall see
later that this training is not only mechanical, but also
participates in the psychological development of the
individual.

I have established a classification of the other methods of
masturbation and have often seen them among patients with
phimosis.

Some boys never masturbate! We may doubt their
assertions, but the tightness of their phimosis suggests
their statements are correct. Ejaculation takes place
during sleep (nocturnal emissions), and more rarely
spontaneously while awake prompted by stimulating events,
among those subjects who attach guilt to contact with the
penis.

Others stroke the glans through the foreskin in the
usual way, but attempt to pull the skin towards the tip of
the penis instead of pulling it back toward the pubis. We
find among these boys the persistence of a long tubular
foreskin such as is seen in infants.

In some cases the boy rolls the penis between two palms
or between one hand and another surface such as the
abdomen, the thigh, a table, the edge of a chair (in
particular the toilet). It is usual in these cases for the
raphe on the underside of the penis not to be in the
midline but more or less displaced to one side or even
spiral; the preputial orifice is often displaced: figure
1.

Mechanical stimulation without use of the hands is
perhaps found most frequently (perhaps causing less guilt).
In general, the boy, flat on his face on his bed, labours
as if for intercourse with the help of his pelvic
musculature, and rubs his penis against the mattress, the
bolster or a pillow, often through a cover in which -- sign
of the times -- he has placed a disposable paper tissue to
avoid stains which would betray his activities to his
mother.

Interfemoral stimulation is found, facilitated by a
penis curved downward (figure 2), unless it is this
activity which determines this anatomical anomaly. This
technique has the advantage that it can be carried out in
company, much as some females have orgasms by squeezing
their thighs, while climbing a rope, or while riding a
bicycle.

Instrumental masturbation: this can be achieved by
vibro-masseur or by showering, but it has never been
demonstrated in this population studied and therefore must
be rare or of occasional practice.

For the record: auto-fellation when mobility allows
it.

Page 5 ---

Roles of Masturbation

Following this analysis, we may consider the purposes of
masturbation.

It serves of course to evacuate the semen secreted by a
pubescent boy. The tension felt by men after a certain time
following the last ejaculation is well known.

It is enjoyable; a boy who has discovered that he can
bring on pleasure by the mechanical stimulation of his
penis recreates the conditions of this pleasure, and this
effort is gratified by orgasm.

For the future masturbation allows the subject to learn
to obtain orgasmic sensations and also to recognise the
erogenous stimuli which create them, to perceive the
beginning of ejaculation, and therefore to find ways to
prevent it. No doubt the regular practice of this activity
forms the basis for the avoidance of premature ejaculation.
Variations are possible on the theme of sexual pleasure and
give the opportunity to explore the field of
eroticism.

To be sure masturbation has a role in preparing the
penis for its future purpose. It seems to me that we could
draw a parallel between athletic training which affects the
development of the athlete who is preparing himself for
competition, and the technique of masturbation which,
during adolescence, serves to overcome organic obstacles to
penetration.
The basis of the therapeutic procedure I
propose to describe is based on this understanding of the
effects of the handling of the penis on the development of
the foreskin and the elimination of phimosis.
Indeed it is apparent that the number of
phimoses observed in a population of boys decreases with
age. Inability to retract the foreskin is normal in
infants, common among young boys, but only persists in
about 10% of the subjects at the end of adolescence.

Finally masturbation contributes to fantasy life and
helps the subject to structure himself mentally in his
future life.

Page 6 ---

Therapeutic Procedure

Faced with a man suffering from phimosis, I propose:

After analysis of the patient's method of masturbation, it
is necessary to explain to him the roles of masturbation
during adolescence, such as are described in the five
preceding points. The discussion has the advantage of
removing feelings of guilt, if necessary.

Next it is advisable to instruct him on the technique that
seems to be most useful, attempting thus to pull back the
foreskin by exposing the tip of the glans. In fact it is only
rarely possible for a boy who has developed for himself a
method that leads to orgasm to replace it initially by
another. Generally the new method fails to give pleasure and
may even tend to impair the quality of the erection. This
could explain why boys fail in their first attempts at sexual
intercourse; a man who has become accustomed to rotational
movements on his penis for several years will be quite unable
to use this technique in the vagina. Therefore I advise
"prescribe" alternating a few pleasurable manipulations known
to be stimulative with the remodelling manipulations. It is
of course essential that the preputial opening be stretched
round the circumference of the fully erect glans. This
technique meets the requirements of the kinesitherapy of soft
tissues, gradual stretching. In some cases I have recommended
instrumental dilatation with the use of a dilator in patients
who agree to this procedure, or I have advised the
introduction of two fingers into the opening of the foreskin
to stretch it. Figure 18.

Perhaps it is logical to draw a parallel between the
preputial ring of the boy and the hymen of the girl. In both
cases there is a mucocutaneous stricture obstructing
intercourse, but allowing the passage of urine and in the
case of the hymen the flow of menses. The opening of the
hymen may occur through traumatic rupture during brutal
penetration, or by gradual and gentle dilatation when the
lover is careful or shy.

Prepuce or hymen, it is the erect glans acting as a mould
(or mandrel) which dilates (and models) the orifice.

Thus the boy can progressively expand his foreskin until
the diameter is equal to that of the erect glans, allowing
him subsequently to proceed to sexual intercourse without
risk of paraphimosis.

Page 7 ---

During the course of this remodelling there will come a
time when the foreskin is sufficiently dilated to uncover the
distal part of the glans but is still too tight to go over
the proximal and larger part; due to the conical shape of the
glans we can then imagine that a strong enough pull might
succeed in sliding the ring into the sulcus, but that the
reverse movement might be impossible, causing paraphimosis
during masturbation. This appears to me unlikely for several
reasons:

- the manipulation is done under visual control of the
subject who is well able to detect the degree of tension in
the foreskin, unlike the situation during sexual intercourse,
particularly when it occurs for the first time;

- if paraphimosis nevertheless did occur in these
conditions it could only be moderately tight and would be
reduced immediately by the subject who is free to readjust
himself at his convenience. Furthermore in this situation
orgasm would not occur (masturbation would be stopped at
once) and so the secondary increase in volume and firmness of
the glans would not take place; whereas in coital
paraphimosis the foreskin enters the sulcus during
intercourse and then orgasm causes further increase in volume
and firmness of the glans making reduction more difficult.
And finally the boy's embarrassment at manipulating himself
in the presence of his partner to reduce the foreskin,
explains the delay during which oedema collects and the
condition becomes established.

Page 8 ---

Results

I had to recommend this treatment for 30 to 40 boys
annually and therefore have observed several hundred cases.
Follow-up in preventive medicine is not usual and many were
not seen again. However about half did return to report a
satisfactory outcome. Some of them grateful to have benefited
from such a gentle and discreet treatment method entrusted me
with other problems and therefore have provided accounts of
the success of the treatment over a longer period.

With regard to patients from the town a number were given
the same advice and I reckon that in 15 years of practice I
never had to refer a single one for surgery.

In a few cases patients agreed to be photographed with the
foreskin stretched on the erect glans at the start, with a
second photograph taken four weeks later. These demonstrate
that retraction of the foreskin was achieved as a rule within
this time.

The illustrations that follow (Figures 7 to 16) show the
outcomes occurring in the same time as that of the scar
formation after surgery. These results encourage therefore
the use of this technique.

I did not come across any failures, but this does not mean
that they did not occur since such cases may have failed to
reattend. It should be pointed out that an attempt at
conservative treatment does not prevent subsequent recourse
to surgery should this prove to be necessary.

Page 9 ---

Discussion

If we must criticise this method of treatment of
adolescent phimosis by the masturbation technique, we must
ask ourselves two questions:
- Is it permissible to discuss masturbation with these
boys?
- Should circumcision be rejected?

About masturbation

* Masturbation is universal in humans.
- It occurs in all young children and is the usual form of
sexual expression among Western adolescents. Georges Mendel
in "Anthropologie Differentielle" points out that "If we
recall the universality of infantile masturbation during the
first years and the near- universality in adolescent boys, we
realise then what a role it must take."

In our society adolescence tends to be prolonged voluntarily
into the third decade and masturbation continues in these
young single men.
- Some married men often make up for the difference in
libido compared with their partner by taking a mistress as
well.
- Mention should also be made of men temporarily or
permanently alone whether willingly or unwillingly as a
result of life's vicissitudes.

* We know that masturbation also forms part of the sexual
relationship of couples and often the woman will masturbate
her partner to avoid intercourse which may be undesirable for
various reasons:

- A young girl who wants to defer her first real
relationship,
- menstruation,
- vulvo-vaginal irritation
- fear of pregnancy or finally just because of a plain and
simple attraction for the penis which she can own or
tame.

Page 10 ---

Masturbation is also a well known means of obtaining or
reviving an erection when mental stimulation is
insufficient.

Masturbation is still the main method of "Safe Sex" as
described for the avoidance of HIV infection and even
recommended by certain governments e.g. Canada.

* Masturbation is in fact advised twice weekly as adjuvant
treatment of chronic prostatis in single men.

* The symbolism of masturbation is found everywhere in
daily life and humour: for example the shaken champagne
bottle ejaculating foam in the hands of the winner of a motor
race.

Is sexual pleasure obtained by masturbation legitimate?

Our senses of sight, hearing and smell have been developed
to ensure survival by detecting predators so that we can
defend ourselves against them, as well as to capture prey and
obtain food. Today in our society these senses are
extensively exploited to obtain pleasure from pictures,
music, sculpture and perfumes. Likewise the sense of taste
necessary to recognise wholesome food is exploited in cooking
and even in tobacco smoking and the enjoyment of wine.

We admit that civilisation allows us this leeway in the
use of our sense organs. We have freed sexual and sensual
pleasure from the confines of reproduction and survival of
the species (who would be satisfied with intercourse three or
four time in their life?); we can therefore allow sexuality
to be expressed freely by individual choice (within the
limits of the liberty of others of course) and free ourselves
from the biblical guilt of sex.

Masturbation has its place within the range of sexual
expression and morality has no rational arguments to displace
it.

To quote Sigmund Freud's Birth of Psychoanalysis: "I
have come to believe that masturbation was the only great
habit, the primitive need and that other appetites, such as
the need for alcohol, morphine, tobacco, are only
substitutes, the products of replacement."

Contemporary Western sexology emphasises the quality of
loving and spiritual relationships in the success of
sexuality. This is very laudable and noble, and also
frequently true, but is in fact neither sufficient nor
indispensable. Sexual technique and the characteristics of
the genital organs also play a part in successful sex. One
need only analyse the factors of sexual nomadism and even
prostitution to convince oneself of this.

The fact that masturbation has a role in the acquisition
of sexual technique and contributes to morphological
development is sufficient to justify it, we think.

Page 11 ---

We may often be tempted to reduce masturbation to a
solitary pleasure derived from mechanical stimulation of the
genitals. It is not so. Despite the fable of "The Animal Sad
After---", there is no doubt that masturbation is
antidepressant and anxiolytic if it is freed from guilt. This
sexual activity distances the individual from the worries and
constraints of daily life lulling him to sleep. whereas the
pre-existing depressed state of mind would have prevented
sleep. By ejaculating the adolescent sends himself to sleep
just as infants and some older children do by sucking their
thumb for comfort.

Furthermore underlying all masturbation there is at the
psychological level both conscious and subconscious
fantasising. Thus the adolescent dreams and rehearses (in the
same way as repeated theatrical performances) sexual
relationships as yet unattainable. In this sense when he
comes to his first sexual relationship he is not entirely
virgin, innocent and inexperienced.

Autoeroticism and fantasising are described by Gerard
Mendel as "productions of the same nature, that is memories,
secondary and associative." and furthermore: "masturbation is
in the last resort only the means to recall, of renewing
intensely the memory of the pleasure arising from the penis,
as well as the whole range of sensory memories which, when
stimulated, constitute fantasy."

Therefore we must get rid of excessive guilt of
socio-cultural origin, and then it seems permissible to
advise an adolescent to direct himself towards a technique
that relates to sexual intercourse.

About circumcision

Circumcision is seen by the patient subjected to it as a
partial castration; it removes part of the genitals, at their
tip, which is particularly significant at the symbolic level.
The patient is ignorant of, as are most doctors, the
functions of the foreskin, which means that the amount of
loss, of damage one may even dare to call it, is unquantified
and therefore unlimited.

Circumcision is akin to amputation, which disgusts us so
much since it is often proposed with the ulterior motive of
preventing masturbation while preserving the ability to
procreate. This attack on sexuality remains still present in
people's minds, and it should be noted that even if the
operation does not occur in France in its bloody and cutting
form it has nevertheless been expressed until very recently
in an insidious way of thinking with tales about ideas such
as "that an honest woman must not enjoy any pleasure" and
that the sexual relationship between the couple was a
"conjugal duty" like other chores. All practitioners in the
field of sexology are familiar with the damage which such
ideas continue to produce in the sexual lives of a great many
patients.

Mankind in general, and especially adolescents, face a
fear of genital abnormality, more as regards size than form
or concerning the ability for sexual function. This fear is
fuelled by the usual boasting of the school playground. On
this

sensitive ground an amputation increases this notion of
abnormality, the more so since we live in a country where men
are not generally circumcised.

More objectively the operation causes an aesthetic
modification, and there is a risk of regarding the penis as
disfigured; a circumcised man in our part of the world may
himself be disgusted and his partners disturbed by the glans
permanently exposed, just as we feel uncomfortable faced with
an ectropion or a prolapse. We are used to a cutaneous
covering of the entire body, and a break or alteration of
this envelope creates by this raw appearance of the
decorticated penis, a feeling of discomfort like the sight of
blood or of a defect in the skin (the labial slit or eczema)
well beyond what reason would lead one to expect; and when
one considers how fragile and sensitive to emotional
disturbances sexual function is, one gets an idea of the
consequences that may result from this mutilation.

Conversely it is important to recognise that in USA the
sisters of a circumcised boy feel this same discomfort when
faced with a partner whose glans is naturally covered.

The foreskin is the eyelid of the glans. Its ablation
denudes the mucosa of the glans and causes more or less
temporarily a dreadful causalgia which the patient could well
do without. The glans is a precious part of the male and in
our minds we know that objects of value are kept in a case.
Circumcision is the ablation of this case.

The foreskin is also an important erogenous zone: it is
perhaps the first such zone discovered by the infant, then it
is the site of the erogenous trigger, particularly effective
at producing an erection since the glans at that time has
only a moderate sensitivity. It seems also that stroking the
foreskin is particularly good for maintaining the erect state
without precipitating orgasm. An informed partner discovers
these properties and knows very well how to communicate
lasting sensations of high quality through the foreskin.
Circumcision removes the nerve endings of this skin surface
depriving the subject of this delightful sensation.

Apart from the foreskin's own sensitivity, the loss
through circumcision of indirect stimulation of the glans
must be taken into account, and the need to discover with
more or less difficulty a new technique of masturbation.

The fragility and delicacy of the mucosa of the glans
explain why stimulation by direct digital massage becomes
painful at once. On the other hand it is bearable and even
delightful when the stimulation instead of being direct is
carried out indirectly through the folds of the foreskin. In
these conditions it is the pressure receptors that are
stimulated. There are variations of pressure within the glans
rather than friction or rubbing on its mucosa. The nerve
endings are not tactile but sensitive to pressure. Note that
some of the masturbation massages the corpus spongiosum,
propelling blood towards the glans, and each wave increases
the pressure there.

Dr. Gerard Zwang, in "Circumcision -- whatever for?"
expresses the same ideas in rich and well-chosen words: "The
child acquires .... the experience of conscious sexual
pleasure. By practising this delicious handling of the penis
indirectly through the foreskin.

The only frictional contact that the glans appreciates,
savours and tolerates is that of the moist and padded vaginal
(or oral) mucosa. The rough, dry friction of the hand or of
the fingers would soon become unbearable if Mother Nature in
her wisdom had not interposed the foreskin as a screen
between the stimulating hand and the very delicate primary
erogenous epithelium. The to and fro movement of the foreskin
on the glans, nicely eased by the lubricating sebaceous
coating, gives rise to this alternating stimulation which is
an effective method of producing orgasm."

Circumcision seems to cause a rapid tensing of the frenum
during penetration and could contribute to premature
ejaculation.

But above all it is the loss of the reserve of skin
provided by the foreskin that damages the physiology of
coitus. The primary function of the foreskin is not to permit
masturbation, even though we may congratulate ourselves for
it, but to allow vaginal intercourse to take place under
optimal conditions without friction between the mucosal
surfaces of the two participants.

Try an experiment: holding the tip of the erect penis of
an uncircumcised boy you can as a rule move your fingers to
the base of the penis without causing the slightest slippage
on the skin. The foreskin unrolls; this skin slides on the
penis; its length and elasticity allow it to travel the
entire length of the organ. There is no other part of the
body where the subcutaneous tissues allow such mobility.
(Photos 19 et seq.)

This explains why sexual intercourse can be prolonged
without causing friction and therefore irritation of the
surfaces in contact, i.e. the penile skin and the vaginal
mucosa. The movement does not occur between these surfaces
but between the penile dartos muscle and its subcutaneous
tissues specially adapted for this function.

Amputation of the foreskin reduces considerably or even
totally this mobility, by removing 4-6 cms of the reserve of
skin and eliminates this amazing function.

The effects of this loss may be slight if the man is a
premature ejaculator, since the very brief intercourse will
not cause irritation, the same if the penis is very short or
moved by thrusts of small amplitude. On the other hand
prolonged and vigorous intercourse risks causing irritation
in spite of natural or even artificial lubrication,
explaining certain cases of female and even male dyspareunia.
I have examined a young man circumcised during military
service; his erection was painful due to the sheer stretching
of the sheath cut too short over the erect corpora cavernosa.
His sexual capacity was as a result at least for a while
totally destroyed, and certainly altered for the rest of his
life.

We may also question whether circumcision, so popular in
the USA, may not be a factor encouraging erosions of the
ano-rectal mucosa in the course of anal intercourse, and may
thus encourage the spread of HIV, since we know that breaks
in the skin or mucosa are the usual portals of entry of the
virus.

Page 14 ---

Conclusion

It would appear then that phimosis which is normal in
infancy diminishes in frequency with age due to the fact of
the manipulation of the penis. It depends therefore on the
practice of masturbation which permits an organised
morphological development in the direction of future adult
sexual behaviour.

In those cases where the manipulation of the penis does
not lead to stretching of the ring of the foreskin, this part
remains of insufficient diameter to expose the glans and
constitutes congenital (primary) phimosis of the
adolescent.

Prescription of kinesitherapy is effective at dilating
this ring, and results in redirecting the patient towards
conventional masturbation. Reduction of the phimosis can be
achieved in a few weeks.

Tackling the subject of masturbation contributes to
removing guilt from a very widespread genital activity, but
one which is often very poorly accepted due to the taboo
which continues without reason to weigh upon it.

Medical treatment of adolescent phimosis, allows when it
is effective (and in the absence of a cutaneous abnormality
it seems to be always effective) the avoidance of the many
problems caused by amputation of the foreskin that is
circumcision. The cutaneous mobility of the penile sheath
being no longer able to benefit from the reserve of tissue is
restricted as a result and the dynamics of coitus are
altered. In North America where circumcision is very
widespread techniques to re-cover the glans by plastic
surgery or stretching have been developed. This latter method
by stretching the remaining skin sets out to restore the
mobility of the sheath just as it would have been prior to
the ablation.

We can be happy that manipulation of the tissues allows
the avoidance of surgical intervention, and in other
circumstances the limitation of the problems when surgery has
unfortunately occurred.